2013 ACC/AHA Guideline on the Treatment of

Blood Cholesterol to Reduce Atherosclerotic

Cardiovascular Risk in Adults

atherosclerotic cardiovascular disease (ASCVD)

It must be emphasized that lifestyle
modification (i.e., adhering to a heart healthy
diet, regular exercise habits, avoidance of
tobacco products, and maintenance of a
healthy weight) remains a critical component
of health promotion and ASCVD risk
reduction, both prior to and in concert with
the use of cholesterol-lowering drug therapies
the use of statins for the prevention of ASCVD
in many higher risk primary and all secondary
prevention individuals without NYHA class II-
IV heart failure and who were not receiving
hemodialysis.
Primary prevention
• the goal is to protect healthy people from developing a disease
• Primordial prevention usually refers to healthy lifestyle choices to prevent
the development of coronary risk factors. Primary prevention deals with
delaying or preventing the onset of cardiovascular disease 
Secondary prevention
These interventions happen after an illness or serious risk factors have already
been diagnosed. The goal is to halt or slow the progress of disease (if
possible) in its earliest stages.
Secondary prevention relies on early detection of disease process and
application of interventions to prevent progression of disease 
Clinical ASCVD is defined by the inclusion criteria for
the secondary prevention statin RCTs :
acute coronary syndromes,
 a history of MI,
stable or unstable angina,
coronary or other arterial revascularization,
stroke,
TIA,
 or peripheral arterial disease presumed to be of
atherosclerotic origin
Initiation of moderate-intensity therapy:
lowering LDL–C by approximately 30% to <50%

high-intensity statin therapy:

lowering LDL–C by approximately ≥50%

a critical factor in reducing ASCVD events

 What’s New in the Guideline

1) Identification of 4 Statin Benefit Groups

2) A New Perspective on LDL–C and/or Non-
HDL–C Goals
3) Global Risk Assessment for Primary
Prevention
4) Safety
5) Role of Biomarkers and Noninvasive Tests
 What’s New in the Guideline
1) Identification of 4 Statin Benefit Groups

Identification of 4 Statin Benefit Groups - in which the potential for an ASCVD

risk reduction benefit clearly exceeds the potential for adverse effects in
adults with:

1. Individuals with clinical ASCVD

2. Individuals with primary elevations of LDL–C ≥190 mg/dL

3. Individuals 40 to 75 years of age with diabetes with LDL-C 70-189 mg/dL

4. Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age

with LDL-C 70- 189 mg/dL and an estimated 10-year ASCVD risk of 7.5% or
higher
 What’s New in the Guideline
2) A New Perspective on LDL–C and/or Non-HDL–C Goals

A. Secondary prevention — Evidence supports high-intensity statin

therapy for this group to maximally lower LDL–C. It does not
support the use of an LDL–C target

In addition, not having a goal of <70 mg/dL for LDL–C means that the
patient who is adhering to optimal lifestyle management and receiving a
high-intensity statin avoids additional, non-evidence-based therapy just
because his/her LDL–C is higher than an arbitrary cutpoint. Indeed, the
LDL–C goal approach can make this patient unnecessarily feel like a
failure.

Non-HDL-C:  total cholesterol  minus HDL cholesterol 

 What’s New in the Guideline
2) A New Perspective on LDL–C and/or Non-HDL–C Goals

B. FH with LDL–C >190 mg/dL — In many cases, individuals with FH are

unable to achieve an LDL–C goal <100 mg/dL. For example, an individual
with FH may only achieve an LDL–C of 120 mg/dL despite use of 3
cholesterol-lowering drugs. Although this patient may have fallen short
of the 100 mg/dL goal, they have decreased their LDL–C by >50%

These patients are not treatment failures, as observational data has shown
significant reductions in ASCVD events without achieving specific LDL–C
targets.

FH: Familial hypercholesterolemia

 What’s New in the Guideline
2) A New Perspective on LDL–C and/or Non-HDL–C
Goals

C. Type 2 diabetes — For those 40-75 years of age with risk

factors, the potential benefits of LDL–C lowering with a
high-intensity statin are substantial

D. Estimated 10-year ASCVD risk ≥7.5%

Data has shown that statins used for primary prevention
have substantial ASCVD risk reduction benefits across
the range of LDL–C levels of 70-189 mg/dL.
 What’s New in the Guideline
3) Global Risk Assessment for Primary Prevention

Use of the new Pooled Cohort Equations is recommended to estimate 10-year

ASCVD risk in both white and black men and women who do not have
clinical ASCVD
to estimate 10-year and lifetime risks for atherosclerotic cardiovascular
disease (ASCVD), defined as coronary death or nonfatal myocardial
infarction, or fatal or nonfatal stroke, based on the Pooled Cohort
Equations and the work of Lloyd-Jones, et al., respectively.
The information required to estimate ASCVD risk includes age, sex, race, total
cholesterol, HDL cholesterol, systolic blood pressure, blood pressure
lowering medication use, diabetes status, and smoking status.
 What’s New in the Guideline
4) Safety

RCTs are used to identify important safety considerations

in individuals receiving treatment of blood cholesterol
to reduce ASCVD risk and to determine statin adverse
effects facilitate understanding of the net benefit from
statin therapy
 What’s New in the Guideline
5) Role of Biomarkers and Noninvasive Tests

There is a concern about other factors that may indicate elevated ASCVD risk, but were not included in the
Pooled Cohort Equations for predicting 10-year ASCVD risk.

These factors include primary LDL–C ≥160 mg/dL or other evidence of

genetic hyperlipidemias, family history of premature ASCVD with
onset <55 years of age in a first degree male relative or <65 years of
age in a first degree female relative, high-sensitivity C-reactive
protein >2 mg/L, CAC score ≥300 Agatston units or ≥75 percentile
for age, sex, and ethnicity, ankle-brachial index <0.9, or elevated
lifetime risk of ASCVD.
Recommendations for Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment
Recommendations for Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment
Recommendations for Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment
Recommendations for Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment
Conclusion
• On the basis of the above tenets and its review of
the evidence, this guideline recommends initiation
of moderate or intensive statin therapy for patients
who are eligible for primary CVD prevention and
have a predicted 10-year “hard” ASCVD risk of
≥7.5%. This guideline recommends that initiation of
moderate-intensity statin therapy be considered for
patients with predicted 10-year “hard” ASCVD risk of
5.0% to <7.5%.